Radio imaging in Mediastinal

masses
 CLASSIFCATIONS
Anatomical Classification

Mediastinum is divided into-

• Superior Compartment
• Inferior Compartment

 Anterior
Mediastinum
Middle Mediastinum
Posterior
Mediastinum
 Compartment Anteriorly Posteriorly

Anterior Sternum Anterior aspect of trachea

Felson Classification and
posterior margin of heart
Middle Anterior aspect A vertical line drawn along
It is based on lateral CXR- of trachea and the thoracic vertebrae 1 cm
Posterior margin behind their anterior
Mediastinum is divided into – of heart margins
1. Anterior Mediastinum
2. Middle Mediastinum Posterior A vertical line Costovertebral junctions
drawn along the
3. Posterior Mediastinum thoracic
vertebrae 1 cm
behind
their anterior
margins
Compartment Main structures /
tissues

Anterior Fat, lymph nodes,

thymus / thymic
remnant, heart,
ascending aorta

Middle Trachea, bronchi,

lymph nodes,
oesophagus,
descending aorta

Posterior Paravertebral soft

tissues
.ANTERIOR MEDIASTINAL MASSES

1- Retro-sternal goiter.
2- Tortuous innominate artery.
3- Fat deposition.
4- Enlarged lymph nodes/ Lymphoma
5- Ascending aortic aneurysm.
6- Thymoma.
7- Germ cell tumour.
8- Pleuro-pericardial cyst.
9- Morgagni hernia.
10- Para-thyroid adenoma.
THYMIC EPITHELIAL NEOPLASMS
• includes:
• Thymoma- non invasive and invasive
• Thymic carcinoma
 Thymoma (Non-invasive)
• The most common primary neoplasm of the anterior mediastinum
and thymus.
• 40 years, M=F
Associations :
1-Myasthenia Gravis(10-20% MG- associated thymoma, 30-50%
thymoma pt has MG)
2-Aplastic Anemia
3-Hypogammaglobulinemia
4-Red cell Aplasia
1-Plain Radiography :
-anterior mediastinal mass anterior to ascending aorta.
-well defined lobulated soft tissue density slightly towards one side of
the mediastinum
-Can demonstrate associated calcification (commonly amorphous /
flocculent).

2 – CT : most sensitive .
-Appear as homogeneous well demarcated solid masses with soft-tissue
attenuation
-located anywhere from the thoracic inlet to the cardiophrenic angle.
-may show cystic or necrotic degeneration.
-Calcification may be present in the capsule or throughout the mass.
-homogenous Contrast enhancement
-
FEATURES S/O INVASIVE THYMONA/ THYMIC CARCINOMA:
• difficult to differntiate on imaging, HPE diagnosis
• poorly defined infiltrative borders
• presence of LAP
• calcification- more common in malignant
• local/mediastinal/chest wall/pericardial invasion
• pleural mets- discrete pleural nodule/diffuse mesothelioma like ( less
likely in carcinoma)
• Masaoka-Koga STAGING SYSTEM:
• Stage I: Tumor capsule is intact.
• Stage II: Invasion of the tumor capsule, surrounding fat, or
mediastinal pleura.
• Stage III: Invasion of surrounding organs.
• Stage IVa: Pleural or pericardial implants.
• Stage IVb: Hematogenous or lymphogenous metastases.
a, b Stage II thymoma

Frontal chest radiograph shows a

hilum overlay sign (arrow) of a
suggestive anterior mediastinal
mass.
CECT scan confirms the presence
of a low heterogeneous anterior
mediastinal mass (arrow).

c, d Stage III thymoma

Frontal chest radiograph reveals a
lobulated mediastinal mass (arrow)
on the right side. Contrast-
enhanced
CT scan demonstrates an enhanced
anterior mediastinal mass (arrow)
with infiltration of surrounding fat
(open arrow)
Stage IVa thymoma
a, b Contrast-enhanced CT scan shows a well-circumscribed, flattened soft tissue lesion in the anterior
mediastinum with calcification (arrow). Note the lobulated contour of the mass and the loss of the fat plane
between the mass and the aorta. Pleural seeding is identified as an enhancing pleura-based nodule (open
arrow).
c Irregular border between the mediastinal mass and the lung parenchyma (arrowhead) is observed as a sign
of locally advanced disease.
 Thymyolipoma
• Rare, benign, well-encapsulated
• The fat content usually constitutes 50–85% of the lesion
1-Plain Radiography :
- appear as large anterior mediastinal masses
-mc site: Cardiophrenic angles
-The larger tumors tend to 'hang down' one or either side of the pericardium and being
soft , they mold themselves to the adjacent mediastinum and diaphragm and often
mimic cardiomegaly .
-May also mimic excessive epicardial fat, diaphragmatic elevation, lobar collapse or a
pericardial cyst.

2-CT :
- well-defined, encapsulated fat conatining mass
-contains small amounts of solid areas and fibrous septa of inhomogenous soft tissue
density.
Thymolipoma
Axial and coronal multiplanar reconstruction of non-contrastenhanced CT scan show
a large and well-defined mass (arrows) that has extensive fat content and contains
small amounts of thin fibrous septa
Thymic cyst
• May be congenital or
acquired.
• On plain radiographs, thymic
cysts are indistinguishable
from other non-lobulated
thymic masses, notably
thymomas.
• CT scans: well-defined cystic
mass demonstrating fluid
attenuation The appearance,
however, may vary if
haemorrhage or infection
complicate the cyst.
Curvilinear calcification of
the cyst wall may occur in a
few cases.